Neonatology Consultation Note (Inpatient)

Date/Time: [date and time of note entry]
Time Seen: [time infant was seen] (Only include if different from note entry time)
Consultant: [name, role, service]
Patient: [Infant name or "Baby [Parent Last Name]"], [MRN], [date/time of birth], [sex]
Location: [unit/bed]
Requesting Service/Clinician: [name and role]
Mode: [in-person bedside / telehealth / chart review only]

Reason for Consult

[Explicit consult question(s) as requested] (State 1–3 concise sentences in the requester's terms, clarifying the clinical decision neonatology is being asked to support.)

Brief Summary

[Single-paragraph synthesis: DOL, gestational age at birth, PMA if preterm; brief birth context including delivery mode and key complications; current clinical status including respiratory support level, hemodynamic stability, neurologic/metabolic stability; link to why consult was requested] (Keep to one concise paragraph; do not include detailed data here.)

Pertinent History

Information Sources: [sources of information and reliability] (Include only if non-standard sources were used, such as outside hospital transfer records, maternal chart, or family report; note uncertainty if applicable.)

(Include only domains relevant to the consult question. For single-domain issues, use a brief narrative; for multi-domain issues, use the labeled elements below.)

Maternal/Prenatal: [maternal age], [G/P], [pregnancy complications relevant to infant], [maternal medications affecting infant], [substance exposures if relevant], [pertinent prenatal labs: maternal blood type/Rh, antibody screen, GBS status with adequacy of intrapartum prophylaxis, HIV, HBV, syphilis] (For safety-critical items not available, explicitly document as "unknown" with plan noted, e.g., "GBS: unknown (outside records pending)". Do not infer maternal labs—document as unknown if not verified.)

Delivery/Perinatal: [delivery date/time], [mode of delivery], [indication if operative], [ROM duration], [amniotic fluid character], [maternal fever], [Apgars at 1 and 5 minutes], [resuscitation interventions with timing/response: warm/dry/stim, O2, CPAP, PPV duration, intubation, compressions, epinephrine, volume], [cord gases if available] (Do not infer resuscitation steps—if not verified, state "unknown" with plan to obtain.)

Neonatal Course: [onset and trajectory of problem prompting consult], [current respiratory support and recent changes], [feeding status and tolerance], [temperature and glucose stability], [sepsis evaluation performed: cultures/labs], [current lines/tubes] (Include only elements pertinent to the consult.)

Medications/Allergies: [current infant medications], [allergies or NKDA], [newborn prophylaxis status if relevant to consult: vitamin K, eye ointment, HBV vaccine]

Objective

Vitals/Measurements: [T, HR, RR, BP, SpO2 with relevant trends], weight [birth weight → current weight, % change], respiratory support [device, settings, FiO2]

Physical Exam: (Focus on systems relevant to the consult question; include key pertinent negatives that affect decisions. For chart-only consults, state "Patient not examined; chart review only.")

• General: [appearance, distress level, work of breathing, color]
• [System-specific findings relevant to consult question, organized by organ system as appropriate: respiratory, cardiovascular, abdomen, neuro, skin, etc.]
• Lines/Tubes: [ETT/CPAP interface, NG/OG, UVC/UAC/PIV, other devices]

Labs/Imaging/Studies: (Include date/time for time-sensitive results; highlight abnormal values.)

• [Blood gas: type (capillary/arterial/venous), pH/PCO2/PO2/HCO3/BE, lactate]
• [Point-of-care glucose values with times]
• [CBC/differential, inflammatory markers (CRP/Procalcitonin)]
• [Bilirubin (total/direct) with risk context if relevant]
• [Cultures: site, date/time drawn, status (pending/positive/negative)]
• [Imaging with brief interpretation relevant to consult]
• [Other studies pertinent to question]

Assessment

[1–3 sentence synthesis tying presentation to consult question] (State leading clinical impression and rationale; frame pattern recognition as clinical impression rather than established fact.)

(List problems in order of severity/urgency.)

[Problem 1]: [Diagnosis or leading clinical impression]

[Current status/severity and key supporting findings; high-risk alternatives considered and why less likely]

[Problem 2]: [Diagnosis or impression]

[Current status and supporting findings] (Include additional problems only as applicable.)

Recommendations

(Organize by problem mirroring Assessment order; provide actionable, execution-ready steps. Use neonatal time constructs: DOL, chronologic hours/days, PMA for preterm.)

[Problem 1]

• Diagnostics: [tests to order with timing and specimen requirements]
• Therapeutics: [medication name, dose in mg/kg, route, frequency, duration]; [respiratory support targets with SpO2 goals and FiO2 weaning parameters]; [feeding plan: NPO vs PO/NG, volume (mL/kg/day), interval]
• Monitoring: [what to trend and frequency: vitals, glucose checks, gases, repeat labs/imaging]
• Disposition: [level of care: nursery vs NICU; consult vs assume primary; transfer criteria]
• Contingencies: [explicit if/then escalation triggers with thresholds, e.g., "If FiO2 >[X]% or worsening retractions → escalate to [specific support] and transfer to NICU"; "If glucose <[X] mg/dL despite feeding → start IV dextrose at [rate] and recheck in [Y] minutes"]

[Problem 2]

• Diagnostics: [tests as applicable]
• Therapeutics: [treatments as applicable]
• Monitoring: [monitoring plan as applicable]
• Contingencies: [escalation triggers as applicable]

(Include Disposition only once unless problem-specific transfer criteria differ.)

Communication

[With whom recommendations were discussed: requesting clinician, bedside RN, family]; [whether recommendations were accepted/implemented]; [follow-up plan: "Neonatology will re-evaluate in [X] hours" / "Available PRN, call with changes"]